AbstractA comprehensive overview of the social, statistical, spiritual and scientific aspects of the homeless population in a wealthy American County reveals challenges that transect all strata of the human equation with complexities that defy simple-quick, easy effective remedies.

Over a period of 84 months 6950 indigent patients were reviewed in consultation from a pool of 26,000 enrolled in the County General Relief Program. Of these patients 17% were seen three or more times, 26% twice and 4% on an annual schedule. The patient population involved 36 nationalities from 59 countries.Effective communication across cultural and language barrier is challenging. The process of taking a history is laborious. Conversations in French, for example, with Vietnamese refugees were effective forces and rewarding and uplifting to them. Hispanic females were infinitely better historians when speaking with a physician in their own tongue. Using an interpreter in interview involves frequent circumlocution, half-truths and misunderstandings. Dialogue is rarely easy seldom accurate and never speedy.

At some point during each consultation we ask "Do you have a spiritual base?" This brought an 83% affirmative response. Many said "It is only god who keeps me going". A young Caucasian male roughly observed, "How could I trust God after what He did to His own Son?"

On the spiritual theme, a review of replies suggest that Buddhists are the most tangential, Muslims the most stoic, Hindus the most loving, Papist the least most hopeful of help from their pastor or church, and Anglo-American Protestants appear to be the most connected to their ministers and religious institutions for practical assistance. The link however, even at best, in tenuous and sometimes complicated by legal overtones and suspicions of hidden agendas. While it is difficult to pinpoint a single outstanding strength springing up from within any group, the Vietnamese demonstrate a special devotion and dedication to the care of elders in their declining years.

The major health problems are listed in Tables I and II. Homelessness is a complex social problem; there are many contributing factors, each of which presents its own difficulties. Most of my patients are unaware of fluctuations in housing and labor markets, the latest mental health policy, or evolving social behavior, or recent employment statistics. Most wonder when next they will eat and where they will sleep that night. In the final analysis, most are homeless because they lack of money to obtain and maintain a dwelling place. Most often, misjudgment, happenstance or misadventure leads to ill health, to loss of earning power, to insolvency, to poverty, to homelessness. It is not a complicated scenario, but it can evolve rapidly!

In over one-half of our study group, the descent into poverty began with a major vehicle accident: Twenty percent of these resulted in head injuries with permanent neurological residuals, another 25% had severe orthopedic injury with delayed or non-union or other complications; (7% of the victims were pedestrians); 61% were not at fault in the accident. 52% of the accidents were alcohol or drug related. 93% of the victims of vehicle accidents no longer owned a car after one year without remunerative work. Or those who still owned a vehicle, 47% lived in it full time. After two years only 1% of this group owned a motor vehicle of any sort.

Orange County has a high population density, and is undergoing rapid growth. Driving in the country is made difficult by multiple, simultaneous freeway projects, severe urban density served by numerous automobile interlinks. There is an increasing need of perpetual defensive driving because the hazards are worsening over time. Any improvement will depend on the increased used of public transportation.

Our survey emphasized the trauma that frequently follows divorce. This trauma appears to be as serious in men as in women and often contributed to homelessness. In males especially, if they "lost" in the financial settlement or their visiting rights with children were terminated the emotional trauma often led to complete breakdown. Judicial chauvinism is still present to an almost unbelievable degree and the female spouses frequently are shortchanged in the process. This subsequent supervision of the children of divorce is almost as haphazard. Some judgment regarding disposition of the children defy even common sense.

In this population, the incidence of AIDS and chemical dependency are no higher than in the general population. (1) One patient explained, "I can't afford a good drunk, Doc". When asked about alcohol abuse. Also violent crimes and weapon fatalities were no higher than in the community at large. The homeless in Orange County appear about average. Mental illness showed a moderate increase among immigrants. Among all the races, the Filipinos had the highest sense of entitlement and in their responses showed the least integrity.

With respect to the official attitude toward the homeless, a police executive in Chicago believes that "tolerance, even sympathy is the dominant theme". (2) This is not our impression. One young Hispanic mother, an epileptic, recognized an oncoming aura, knew she was about to have a seizure and was rushing towards the emergency room entrance of a hospital. She was stopped by two male Hispanic policemen, who ignored her pleas and her explanation, was treated quite roughly, and pushed into the police car, where she convulsed all the way to jail.

Those homeless who feel threatened by a "third strike" situation (after two offences, the law permits a long prison term for the third) are afraid to venture out to seek work of any kind. They distrust their parole and probation officers. Several said they were afraid of "being set up", and for that reason urged that they not be assigned to any work site.

In contrast, not one offender seen in consultation ever believed that he/she was guilty. According to them "they were, in the wrong place at the wrong time," or doing their best friend, a favor or their actions were misunderstood by impulsive officers of the law.

Churchill said, "Generosity and gratitude are the two virtues we most rarely encounter". Within the homeless population, criminality and guilt seldom encounter each other. Denial is paramount, I wonder if sociologists have ever studied this. Many of these patients (31%) have attempted to obtain Social Security Insurance. Some have no American Citizenship and their waiver for payment permission of Social Security Benefits is delayed or mysteriously lost, etc. People in prison need to reapply for these benefits after they are released. Delays are frequent, etc. Many patients find the most inequitable aspect is the "all or nothing" rigidity of the variant "disability." Impairment to one medical doctor is malingering to his peer, and judges become confused, etc. Reevaluation, yet again, of the entire structure may become mandatory, should a class action suit get on a calendar in a court of law somewhere, possibly in California or New York or even Texas, three of the most politically innovative states in the American union.

This study makes it clear that a certain number of welfare patients are incompetent. For whatever reason, they are not teachable; they cannot learn, and do not improve. Whether because of psychodynamic development or neuro-biological defects they are unable to perform. These are among those who "fall through the cracks" in any assistance program and suffer most. They should be awarded SSI benefits promptly after minimal scrutiny.

SummaryHow can we help the homeless? Three possibilities suggest themselves. With competent administration and management of the funds, the allocation of the first 0.01% of the net profit of the nations 50 most profitable companies, could relieve 90% of homelessness in a period of 18 months.

Properly used, a flat tax of 1% on all tele-evangelists, churches, and religious organizations in the country could, eliminate homelessness in two years. Objections from the churches probably would be muted, because all these institutions preach feeding the hungry, clothing the naked, and healing the sick. The monies collected from them would be used exclusively for the purpose and for these people.

Finally on a lesser scale, each of us can intervene on an individual, person-to-person, case-by-case basis for immediate, one-time emergency situations to save the individual homeless person from complete collapse: eg. A rent payment to avoid eviction, a badly needed hernia repair when a surgeon cannot be found, a valve job to revitalize a truck to save it from repossession, etc. These make-or-break situations, successfully handled, often turn the patients destiny around on the brink of disaster, the homeless have no way to go but down or up. A small immediate push sometimes can turn the tide from complete defeat into a small step toward eventual recovery and independent existence.

As my dad used t say, "It's difficult to help someone up the hill without getting to a higher place yourself."